Ensure patients give informed consent

Patients must understand the implications of a procedure before it is carried out, says Dr Mona Kular.

Seeking consent from patients is an important part of working as a GP. It contributes to the integrity of the doctor-patient relationship and is essential to patient autonomy. Obtaining consent is a legal requirement for carrying out all procedures, from simple chest examinations to more complex procedures such as minor surgery.

Informed consent
Patients have a right to all pertinent information about a situation, procedure or investigation before they give consent.

Once they have been informed, patients can choose to accept or refuse a particular course of action, even if refusing it could be detrimental to their health.

The process of obtaining consent involves giving patients information in an understandable way. How you give the information will depend on the nature of the situation, its complexity, any risks involved and the patient's own wishes.

It is important to see that the patient fully understands the information presented to them and to find out if they need any further information before they can make a decision.

No information should be withheld from the patient and any questions should be answered fully.

Information required
The information that you need to give the patient before they consent to the procedure will vary according to the situation. As a rule, there are seven areas that should be covered (see box far right). These can be adapted to suit the needs of the situation.

The information given to patients should be up to date and any communication or language needs should be taken into account.

Patients should also be given time to reflect upon information given to them and may want to consult with relatives or friends.

Express consent
When patients have agreed to a procedure or treatment either orally or in writing they have given express consent.

For some procedures, particularly those that are more complex, written consent is a statutory requirement.

In general, written consent should be obtained for procedures if they carry risks or side-effects, are part of a research programme or if they could have other important health or lifestyle consequences.

In situations where a patient appears to consent to a procedure without explicitly giving consent orally or in writing they are said to have given implied consent. These situations should be handled with care.

For example, if a patient removes an item of clothing for an examination, this does not in itself mean that they have understood and agreed to the proposed examination.

Special considerations
There are certain situations in which the rules of consent differ. These are:

Capacity. Adults are deemed to have the capacity to make decisions unless it is clear that they are unable to understand the information presented to them. In these cases it may be necessary to consult more experienced colleagues or even apply to the court for a ruling.

Mental incapacity. Consent cannot be given or withheld on behalf of patients deemed to lack capacity. They can be treated in their best interests, if they comply, and if not can be treated for mental disorders under the Mental Health Act 1983. Physical disorders arising from mental illness may also be treated.

Emergency situations can arise in which it is impossible or impractical to obtain consent.

At these times it is our duty to act in the patient's best interest, providing care that is clinically indicated and necessary to save lives or avoid acute deterioration in health, while respecting any advance statements that may have been drawn up.

Children at age 16 are deemed to have the capacity to give consent. Under the age of 16 children are deemed to have capacity if they are Gillick competent.

If not competent, those with parental responsibility can give consent for procedures in the child's best interests. They can also refuse consent, but this can be overruled by the courts if necessary.

Research and screening
Consent is just as important for research and screening as for any other procedure.

Screening comes with risks of false negatives and positives that can have significant consequences. Patients need to be fully informed about all these risks before deciding to be screened.

Research can lead to unpredictable results or side-effects. Patients need to be informed about all aspects of the research programme, including that they can drop out at any time.

Dr Kular is a specialist training registrar in Nottingham.

Learning points
Principles to be aware of when seeking patient consent:

1. Consent must be obtained before carrying out any procedure.

2. Patients need to be fully informed before they can give their express consent.

3. Patient consent should be express and not implied. Express consent can be written or oral.

4. There are special situations where the rules of consent differ, such as in emergencies or in treating patients who are deemed to lack the mental capacity to give consent.

Patients should be informed about

  • Details of diagnosis and prognosis.
  • Treatment options, including the option to do nothing.
  • Purpose and details of the proposed treatment, including the possible side-effects, the effects on lifestyle, the risks and benefits and whether there is any experimental element.
  • Assessment and monitoring of their condition.
  • Details of the doctor who will oversee the patient's care and whether trainees or students will be involved.
  • Their right to change their mind or seek a second opinion.
  • Details of any costs that may be incurred.

GMC, Seeking patients' consent: The ethical considerations. November 1998. www.gmc-uk.org .

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